Application Form

I have enclosed list of following documents along with my application form. - high school diploma. - college/university diploma, transcripts, course descriptions (if available). - recent passport size photograph. - recent medical certificate, stating that the candidate is free from any chronic and communicable disease and ...
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DAVID TVILDIANI MEDICAL UNIVERSITY AIETI MEDICAL SCHOOL 2/6 Ljubljana Str., Dighomi, Tbilisi 0159, Georgia Phone: + (995 322) 516 898, Fax: + (995 322) 527 196 Email: [email protected] Web: www.dtmu.edu.ge

Application Form

Personal Information Family name _______________________________________________________________________________________ * Given name(s) _____________________________________________________________________________________ * Sex _________Date of Birth (___/___/______) ___________________Place of birth ________________________ * Nationality_________________________________________________ * Proficiency in English ____________________ * Contact details (in your country) Address___________________________________________________________________________________________ ___________________________________________________________________________________________ City______________________________ Country _________________________Post/ Zip Code________________ Telephone_________________________________Email__________________________________________________

Passport Passport number ____________________________ Valid till_____________________________________________ * Citizenship________________________________________________________________________________________ *

How did you hear about DTMU

____________________________________________________ *

Educational Qualifications Name of Institution_______________________________________________________________________________ * Qualifying Examination___________________________________________________________________________ * Name of Certifying Board_________________________________________________________________________ * Year of Completing Higher Secondary Qualifying Examination____________________________________ * Additional Educational Qualification (If Any) 1. _________________________________________________________________________________________________ 2._________________________________________________________________________________________________

DECLARATION I have enclosed list of following documents along with my application form - high school diploma - college/university diploma, transcripts, course descriptions (if available) - recent passport size photograph - recent medical certificate, stating that the candidate is free from any chronic and communicable disease and suitable to study in Georgia - copies of all pages of passport I hereby submit all available school documents with my application. I understand that my documents will be evaluated. I request the university to admit me in first year of medical education upon successful evaluation of documents. I confirm that this declaration fully accords with my intentions, and hereby sign the application form.

Signature: Name: Date: *Mandatory fields